Run, think about diabetes, eat, think about diabetes, sleep, repeat

The Bedside table of a type one diabetic: water, insulin (fast and slow acting), JDRF pencil case to carry it around in, emergency jelly babies, old needle packets!

The Bedside table of a type one diabetic: water, insulin (fast and slow acting), JDRF pencil case to carry it around in, emergency jelly babies, old needle packets!

I spend a lot of time thinking about diabetes. When I run I’m thinking about how I’m feeling, do I need to test my blood to avoid the risk of hypo, does my level of effort mean my liver is releasing glucose into my blood or not? When I eat I obviously think about how many carbs I’m about to eat and how sensitive I think I’m going to be to the insulin (my wife will say “you’re not being very sociable.” And then, “oh, you’re doing maths” as she sees me looking at my plate). During the day at work I’m often wondering if I’ve got symptoms of high or low blood sugar or whether I’ve just drunk too much coffee. I should give up the coffee really, but there is only so much self discipline one can impose on oneself.

Despite thinking about diabetes a lot, I think about lots of other things too, and there are sometimes crucial points in the day where I forget that I’m diabetic. One happened this morning when I left the house. Without my insulin. The picture above is my bedside “table” (it’s a cardboard box) where my insulin stayed all day.

I realised after I had made myself a big bowl of muesli and banana. In fact, I only realised after I had started eating. Minor alarm – “I haven’t taken my insulin yet” – turned to major alarm – “I don’t have my stupid insulin!” Cue pouring the bowl of cereal into the bin and marching upstairs to buy fried eggs, bacon, sausage (5g of carb, but I thought I could handle that) and tomato. Blood sugar only mildly up after all that luckily, and it returned to 5.7 (perfect!) after a couple of hours.

I was also out for a work lunch. Luckily the special was swordfish and salad so I could order a carb free lunch. One of the people I was lunching with gave me a knowing look when I declined to order a side of potatoes. He knows I have a huge appetite, and knew exactly why I was abstaining! I even had to eat a cereal bar (30g carb) over the course of the afternoon to keep my blood sugar from dropping too low. This requires another act of will power. Someone as greedy as me finds it really difficult to eat only half a cereal bar in one go.

By home time blood sugar had dropped to 4.1 so I even had to eat some jelly babies before running home.

This is all part and parcel of being a (forgetful) diabetic. Luckily I’m still in the honey moon phase, and I’m no longer ill, so I got away with it.

All's well that end's well. The ideal range for Blood Glucose is between 4 and 8 mmol/litre. Mine was briefly over 9 this morning (I'd already eaten too much cereal before I realised I didn't have my insulin), but has been very well behaved since then.

All’s well that ends well. The ideal range for Blood Glucose is between 4 and 8 mmol/litre. Mine was briefly over 9 this morning (I’d already eaten too much cereal before I realised I didn’t have my insulin), but has been very well behaved since then.

Diabetes Management

Skiing with type 1 diabetes

I’m currently in Chamonix for my first skiing Christmas. I was ridiculously keen to go skiing again. But also aware that it was my first time skiing with type one. One of the main reasons I started all my running was so that I could understand my blood sugar control better to prepare me for skiing. I’d like to do things like this again safely with type 1, so I’m really motivated to control the condition.

Data Skiing

Will information liberate me?

“Knowledge is power. Information is liberating.” Kofi Annan.

Not a bad place for a hypo! The photo doesn't do it justice, but we came round the corner of the hill, the clouds parted and we had a spectacular view of the Argentiere Glacier. By testing regularly during exercise, I hope to gain a better understanding of how to manage my blood sugar and minimise risk.

Not a bad place for a hypo! The photo doesn’t do it justice, but we came round the corner of the hill, the clouds parted and we had a spectacular view of the Argentiere Glacier. By testing regularly during exercise, I hope to gain a better understanding of how to manage my blood sugar and minimise risk.

When I was diagnosed, one of my first questions to Dr Powrie was “can I still climb mountains and run long distances?” He told me that it would be complicated, and that I should maybe reign in my ambitions.*

I’m not going to reign in my ambitions.

Having diabetes makes doing prolonged physical activity a more risky because of the risk of experiencing a hypo (low blood sugar). It is particularly important to bear this in mind when half way up a mountain, because it is hard to get a paramedic up a cliff, and it can endanger the diabetic and his companions.

Fortunately, mountaineering is already a risky business involving lots of kit. When climbing a mountain, or descending a snowy slope on skis, one has to constantly assess risk of falling, of weather, of avalanches etc. So I already have transferrable skills I can use to manage diabetes – it’s just an additional risk factor to manage, and it requires another load of kit.

The desire to keep on doing all this stuff has given me the motivation to learn as much as I can about the condition, and part of that is to collect a load of data. I’m suffering from a bit of “computer programmers block” at the moment and can’t quite decide how best to organise the mountain of data I’m creating every day. The crux of the problem is as follows: a normal person has to eat the right food to fuel their body whilst spending a day running or climbing. I need to do that, but also take the right mix of long and short acting insulin, and the right amount of carbs to stop me from experiencing hypos.

I’ve already found, for instance that if I’m running fast (for me, I’m defining a “fast run” as any distance up to half marathon) my blood sugar generally goes up for the first 45 minutes of exercise. If I’m doing less intense exercise, my blood sugar will go down. If I’ve taken short acting insulin before exercising (for instance if I’ve gone for a walk after lunch) my blood sugar will drop fairly quickly. It’s all very complicated and whilst my intuition is improving, I think I need to analyse the data more formally as well to give me the best chance of optimal blood sugar control, and decrease the probability of bad hypos.

I’ve created some charts to help me. Here’s an example of two runs I did – one half marathon (fast) and one run over two and a half hours which involved a climb of 1200m (slow).

The chart shows how my blood sugar changed depending on exercise and carb intake. I was running during the period between the green boxes. The blue diamonds show my blood sugar at different times, and the red boxes show how many grams of carbohydrate I ate at different times. Running fast (I have defined my half marathon pace as "fast") seems to mean that my liver releases glycogen into my blood stream at a quicker rate than I can absorb the glucose for the first 45 minutes of a run. After an hour I started eating jelly babies to prevent my blood sugar from falling too much.

The chart shows how my blood sugar changed depending on exercise and carb intake. I was running during the period between the green boxes. The blue diamonds show my blood sugar at different times, and the red boxes show how many grams of carbohydrate I ate at different times. Running fast (I have defined my half marathon pace as “fast”) seems to mean that my liver releases glycogen into my blood stream at a quicker rate than I can absorb the glucose for the first 45 minutes of a run. After an hour I started eating jelly babies to prevent my blood sugar from falling too much.

This is the same kind of chart, but it was a very different run. I ran for almost two and a half hours, and climbed 1200m. It's impossible for me to run fast doing that, and from the limited data I have (I didn't test after half an hour which would have showed the initial response from my liver) I would say that at this slower pace my liver does not release so much glycogen into my system.

This is the same kind of chart, but it was a very different run. I ran for almost two and a half hours, and climbed 1200m. It’s impossible for me to run fast doing that, and from the limited data I have (I didn’t test after half an hour which would have showed the initial response from my liver) I would say that at this slower pace my liver does not release so much glycogen into my system.

The data collection will continue, and I’m really looking forward to doing more long runs to find out about my insulin and carbohydrate requirements.

*I don’t want to make Dr Powrie sound like a killjoy. It was good of him to manage my expectations. I’m very lucky to have found such a good doctor and I have found him very supportive over the past two months.

Data

Hypos

Upon diagnosis, a type 1 diabetic learns about “hypos” straight away. The word is short for “hypoglycemia” which literally means “low sugar blood”. Wikipedia has loads of information on it here. Having a bad hypo is BAD, so we need to be able to recognise and treat them.

In a normal human being, glucose levels in the blood are regulated by the pancreas. Beta cells secrete insulin to bring glucose levels down, and glucagon to bring blood glucose levels up. For a diabetic, if for whatever reason blood glucose starts falling to unsafe levels, there is a problem. Because we have to inject insulin (we have no beta cells), once injected that insulin stays there – still pushing down the level of blood glucose. A normal person would just stop producing it. Secondly a diabetic’s pancreas will not produce glucagon (according to Wikipedia anyway: I don’t understand why, so plan to check with my doctor). [Edit: I asked Dr Powrie and he told me that type 1’s do still have cells which produce glucagon. He said that the absence of beta cells may impair the function of cells producing glucagon, but that its complicated and that the process isn’t fully understood.] So the first (and maybe second) lines of defence against low blood sugar do not exist in a diabetic.

Symptoms of a hypo, according to diabetes.co.uk are feeling dizzy, feeling hungry, a change in mood, feeling sweaty, finding it hard to concentrate or trembling. In severe cases it can lead to unconsciousness, seizure or even death! In terms of blood sugar levels, the rule of thumb seems to be that less than 4 mmol/l is a “hypo”. Given that healthy adults have between 4-7 mmol/l of glucose in their blood, if a diabetic is managing their blood glucose to be near that level, the odd hypo is inevitable.

Dr Powrie is currently getting me to manage down my very high levels of glucose upon diagnosis (30-ish) to aim at 6-12 currently. So I haven’t had a hypo yet. On my second or third night as a diabetic, after taking my long acting insulin before sleep, I did lie awake for a bit wondering if I was having a hypo. I wasn’t. I then came close after walking back from the hospital last week – I was 4.3 when I got back to the office.

So it’s still the unknown for me!

A complicating factor for someone who is active, is that some of the symptoms of hypoglycemia  are the same things that we experience whilst exercising. I’m beginning to see how running a marathon could be a challenge…

In the past day and a half I have now run twelve miles in three lots of four mile runs. After the first two runs, my blood sugar rose from 8-ish pre-run to 11-ish post run. Then just now, my blood sugar fell from 7.6 pre-run to 5.2 post-run. Below the level I’m aiming at. Panic!!! 🙂

To treat a mild hypo (blood sugar level under 4), one must consume 15g of high GI carbohydrate like jelly babies, coke, juice or glucose tablets. To treat a severe hypo, when a person is unconscious, glycogen needs to be injected into the muscle. This stimulates the liver to produce glucose.

In my case just now, I decided I had enough leeway to eat something nice rather than something sweet like a jelly baby, so I had two mini nectarines (yum!) and a bottle of alcohol free Becks beer (drinking alcohol increases the risk of a hypo several hours after consumption). I reckon that’s about 19g of carbs and my sugar level has now gone up to 8.9. Disaster averted!

In the future I will need to be able to judge whether my identical run will increase or decrease my blood sugar. I will ask Dr Powrie for advice of course. My theory is that it has to do with how much short acting insulin, I’ve taken beforehand. But I won’t bore you with the details.

In any case, I’m now more motivated to run than ever. The more runs I do the more data I will collect and the more likely I’ll be able to go ski touring and run a marathon.

What is type 1?